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Parliament is being urged to crack down on the illegal importation of prescription medicines after a user's death.
Mental health patient Graham David Goodwin of Blenheim died after taking drugs that included an anti-depressant he had ordered from overseas and had mailed to him.
It is believed to be the first death of its type where imported drugs were involved.
Wellington coroner Ian Smith said: "It is clear that with the advent of the internet, it is very easy to order medicines from overseas sources and it's becoming increasingly difficult for customs to detect and seize such medicines."
Mr Goodwin, a 44-year-old father of two, was found dead at his home on January 28 last year.
The official cause of death was poisoning by an overdose of the drug Doxepine. However a drug he imported, Mirtazapine, could have enhanced its effects on the central nervous system, a pathologist said.
Police found a large array of prescription medicines at his home, many from unknown sources.
"Of these medications, the large quantity of Mirtazapine, an anti-depressant drug which requires a prescription from a medical practitioner, were clearly sourced from overseas via Express Mail Service," Mr Smith said.
"They were purchased by internet from a website. This process operates via an Indian mail order service."
Importing a prescription medicine can be an offence under the Medicines Act, which can result in up to three months' jail or a fine of no more than $500, with a further fine of up to $50 a day for a continuing offence.
Mr Smith said authorities should seek a law change to allow "a much longer prison sentence" and a "substantial increase in the alternative of a fine".
The Customs Service said it was possible the medicines sent to Mr Goodwin through the Auckland Mail Centre were not identified as prescription drugs, that the packaging satisfied Customs it was legal, or that it was it was released back into the mail system in error.
Since Mr Goodwin's, death, Customs had employed an investigation and enforcement team that included pharmacists on site. This had increased the capture of prohibited medicines at the border.
Mr Smith has also recommended an advertising campaign warning of the risks of imported prescription medicines "and the fact a person may be convicted and sent to prison for such activities".
